Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mn Veterans Home - Luverne during CMS and state inspections, most recent first.
A resident with moderately impaired cognition, hemiplegia, and a need for staff assistance with transfers was being unloaded from a facility mobility van using a mechanical wheelchair lift when the van driver, who felt overworked and distracted, pushed the wheelchair backward without raising the lift platform to van level or applying the safety belt. The resident and wheelchair fell backward to the ground, causing head and wrist injuries and exacerbation of back pain, with subsequent documentation of vertebral wedging, significantly increased pain requiring narcotic analgesics, confusion, lethargy, and greater dependence in ADLs and transfers. Interviews with the safety officer and authorized drivers revealed that staff received only initial, undocumented training on van and lift use, with no annual refresher training, no formal competencies, and no written policies or manuals governing operation of the van, wheelchair lift, or resident transport, contributing to the unsafe transfer that led to the fall.
A narcotic emergency kit (E-Kit) in the medication room was found with expired medications, including Morphine Sulfate and Lorazepam, due to a lack of proper monitoring and documentation by nursing staff and the consultant pharmacist. The E-Kit was not replaced before its expiration date, despite policies requiring routine checks by both nursing staff and the consultant pharmacist.
A facility failed to prevent potential drug diversion and misappropriation of narcotic medication when an LPN altered narcotic logs and removed a hydrocodone tablet from an E-Kit without proper reporting. The LPN admitted to cutting the E-Kit lock and altering records to correct a count discrepancy. The facility did not notify law enforcement or verify the compromised medication, and the DON did not document audits or review past administrations for discrepancies.
A facility failed to report a suspected drug diversion involving an LPN who tampered with an emergency narcotic kit and altered narcotic logbooks. The LPN admitted to taking a hydrocodone tablet to correct a perceived discrepancy and did not report the incident. The DON destroyed the compromised tablet without verifying its contents and did not notify law enforcement or the Board of Nursing. The consulting pharmacist was not informed, and the facility did not follow its policy to report such incidents to authorities.
A facility failed to thoroughly investigate a potential drug diversion and misappropriation incident. Medications, including narcotics, were left unattended, leading to a missing hydrocodone tablet. LPN-A altered narcotic logbooks and improperly handled medication without documentation. Despite some reminders to staff, there was a lack of documented training or audits, and the consulting pharmacist was not informed.
A facility failed to secure a package of routine and controlled narcotic medication upon delivery. An LPN found the package left unattended at the door and placed it in an unlocked report room without notifying the DON or administrator. The DON later discovered the medications were left unsecured, posing a risk of diversion. The facility's policy did not specify immediate custody upon delivery.
Failure to Safely Operate Mobility Van Lift Leads to Resident Fall and Increased Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe transfer for a resident who required use of a mobility van mechanical lift, resulting in a fall from the van lift platform to the ground. The resident had moderately impaired cognition, required staff assistance with dressing, personal hygiene, and transfers, and used a manual wheelchair but was independent with mobility. Diagnoses included heart failure, arthritis, aphasia, hemiplegia, and seizure disorder. Prior to the incident, the resident’s pain assessments and MAR entries showed low pain levels managed with scheduled acetaminophen, and the resident denied having pain despite receiving scheduled pain medication. On the day of the incident, the facility van driver lowered the wheelchair lift platform fully to the ground to ensure it was on level ground, but then forgot to raise the platform back up to the van and did not attach the safety belt before attempting to unload the resident. The driver entered the van and pushed the resident’s wheelchair backward, not realizing the lift platform was not in position, causing the resident and wheelchair to fall backward off the edge to the ground. The resident sustained a laceration to the back of the head, a large hematoma and jagged skin tear to the right hand/wrist, and complained of back pain. Hospital evaluation identified wedging of several vertebrae of uncertain age, demineralized bones limiting detection of acute fractures, and musculoskeletal back pain, with concern that vertebral compression fractures might be chronic but also possibly exacerbated by the recent injury. Following the fall, documentation and interviews indicated the resident experienced a significant change in condition. The resident returned from the hospital with lower back pain, was not alert or oriented per baseline, and complained of pain with transfers and rolling in bed. Therapy and nursing notes documented poor transfers, increased confusion, and pain requiring use of a full-body lift and increased assistance with ADLs, including bed mobility, transfers, dressing, and locomotion. Pain ratings increased substantially, with frequent reports of severe pain interfering with therapy and daily activities, and the resident required multiple narcotic pain medications, including fentanyl patches, hydrocodone-acetaminophen, and oxycodone, with associated somnolence and lethargy. Staff and family interviews described the resident as more confused, very sleepy with pain medications, not eating well, not participating in activities as before, and having ongoing significant pain and functional decline after the fall. The events leading to the deficiency were further linked to systemic issues in staff training and facility procedures related to the mobility van and wheelchair lift. The facility safety officer reported that he provided initial training to staff on the van and lift when they were newly hired or began using the van, but there were no yearly refresher trainings, no formal competencies, and no documentation or proof of training or competency for authorized van drivers and lift operators. He also stated there was no policy or lift manual for the vehicle, and that instructions were limited to those posted on the van doors. The van driver involved in the incident stated he had been driving the van for approximately four years, had initial training when he started, and had been working many extra shifts, feeling overworked, stressed, and distracted at the time of the incident. Another authorized driver confirmed that she had only received initial training and a quick rundown when a new van was obtained, without formal wheelchair lift training or annual competency. The administrator acknowledged that the root cause analysis after the fall identified the lack of annual training and the absence of a policy on the van’s wheelchair lift as contributing factors.
Failure to Replace Expired Narcotic E-Kit
Penalty
Summary
The facility failed to ensure the timely replacement of a narcotic emergency kit (E-Kit) before its expiration date, as observed during a survey. The E-Kit, located in the medication room of the [NAME] Wing, was found with an expired pharmacy date sticker. The registered nurse (RN-A) confirmed that while the E-Kit was checked during each shift narcotic count, there was no individual log to verify that the medication had not expired. The narcotic book only documented the accuracy of the count, not the expiration status. The director of nursing (DON) acknowledged that the E-Kit contained outdated medications, including Morphine Sulfate and Lorazepam, and expressed that the expiration should have been noted during the multiple shift counts. The consultant pharmacist, who conducted monthly medication reviews, admitted to not checking the E-Kits for expiration dates. The Minnesota Veterans Home Pharmacy manager expected both the consultant pharmacist and nursing staff to monitor the E-Kits for expiration during narcotic counts. The facility's policy required nursing staff to routinely monitor medication storage areas to prevent the use of outdated medications. Additionally, the operating procedure for pharmaceutical services indicated that the consulting pharmacist was responsible for reviewing the E-Kit during monthly reviews, which was not adhered to in this instance.
Failure to Prevent Drug Diversion and Misappropriation of Narcotics
Penalty
Summary
The facility failed to protect a resident from potential misappropriation of property and potential drug diversion involving narcotic pain medication. The incident began when the Director of Nursing (DON) was informed by an on-call registered nurse (RN) that a hydrocodone tablet was missing from the emergency narcotic medication kit (E-Kit). A licensed practical nurse (LPN) discovered that the lock on the old E-Kit appeared to have been cut, and the narcotic count was inconsistent. The narcotic book showed discrepancies, with entries signed by an LPN who had altered the logbook by writing over entries and tearing out a page. The investigation revealed that the LPN admitted to cutting the lock on the E-Kit to replace a missing hydrocodone tablet for a resident, intending to correct the count. The LPN altered the narcotic logbook and failed to report the discrepancy to any staff. The LPN also admitted to placing an extra dose in a medication cup labeled 'Destroy' but did not inform anyone about it. The DON and another LPN destroyed the compromised tablet without verifying its contents, and the facility did not notify law enforcement or the consulting pharmacist about the potential drug diversion. The resident involved was dependent on staff for all activities of daily living and had a diagnosis of lower back pain and neuropathy. The resident's medication administration record showed that the LPN had signed off on administering hydrocodone on the day of the incident. The facility's policies required controlled medications to be reconciled by two nurses each shift, but the procedures for handling suspicions of a crime or evidence gathering were not followed. The DON did not document the audit of narcotic logbooks or review past administrations by the LPN to identify any patterns of discrepancies.
Failure to Report Suspected Drug Diversion and Notify Authorities
Penalty
Summary
The facility failed to report a suspicion of potential drug diversion to law enforcement and did not notify the Board of Nursing regarding a nurse whose employment was terminated. The incident involved a missing hydrocodone tablet from the emergency narcotic medication kit (E-Kit). The director of nursing (DON) was informed by an on-call registered nurse (RN) that a hydrocodone tablet was missing. It was discovered that the lock on the old E-Kit had been tampered with, and the narcotic count books showed inconsistencies, with entries signed out by a licensed practical nurse (LPN). The LPN admitted to altering the narcotic logbook and taking a hydrocodone tablet from the E-Kit to correct a perceived discrepancy in her medication cart. The investigation revealed that the LPN had cut the lock on the old E-Kit and taken a hydrocodone tablet to replace a missing one in her cart. She later found the missing tablet and attempted to return the extra dose to the E-Kit, but instead left it in a medication cup labeled 'Destroy' in the med cart. The LPN did not report the incident to any staff and altered the narcotic logbook to make the count appear correct. The DON and another nurse destroyed the compromised tablet without verifying its contents, and the facility did not notify law enforcement or the Board of Nursing about the potential drug diversion. The consulting pharmacist was not informed of the incident and was not involved in the investigation. The facility's Vulnerable Adult-Resident Protection Plan Policy requires reporting such incidents to state licensing authorities and law enforcement, but this was not done. The DON conducted an audit of the narcotic count logbooks and ensured that narcotic counts were completed by two licensed nurses at the end of each shift, but did not document these actions or notify the appropriate authorities.
Failure to Investigate Drug Diversion and Misappropriation
Penalty
Summary
The facility failed to conduct a thorough investigation following a reported potential misappropriation of resident property and potential drug diversion. The incident began when a delivery driver left a green tote containing medications, including narcotics, unattended at the facility. LPN-C found the tote and distributed the medications to the appropriate wings. However, when delivering to the [NAME] Wing, LPN-C could not locate the RN and informed LPN-A that the medications were left on a table in the report room. LPN-A acknowledged this but left the medications unattended and unsecured for an unknown period. Later, LPN-B discovered that the narcotic emergency kit (E-kit) had a cut zip tie and was missing one hydrocodone tablet. Upon further investigation, inconsistencies were found in the narcotic medication logbooks, particularly on R1's medication count page, which had been altered and tampered with by LPN-A. LPN-A admitted to removing a hydrocodone tablet from the E-kit without proper documentation or notification, intending to replace a missing tablet from R1's blister pack. The missing tablet was later found, but LPN-A failed to follow proper procedures, including completing triple checks during medication administration. Interviews with staff, including LPN-C, LPN-B, and the DON, revealed that while some measures were taken, such as reminders to complete narcotic counts with two licensed staff, there was a lack of documented training, audits, or competencies following the incident. The consulting pharmacist was not informed of the potential diversion and was not involved in the investigation process. The facility's Vulnerable Adult-Resident Protection Plan policy outlines the need for reporting misappropriation incidents, but the investigation did not fully adhere to these guidelines, and there was no documentation of the investigation's findings or actions taken.
Failure to Secure Delivered Narcotic Medications
Penalty
Summary
The facility failed to ensure the immediate security of a package containing routine and controlled narcotic medication upon its delivery. An LPN discovered that the medication delivery, which included a narcotic E-kit, had been left unattended at the door. The package was secured with two plastic zip ties, but it was not immediately taken into staff custody. The LPN then delivered the medications to the appropriate wings and informed another LPN that the newly delivered medication was placed on a table in an unlocked report room. However, the LPN did not notify the Director of Nursing (DON) or the administrator about the unattended delivery, which posed a risk of potential diversion. The DON was not informed of the unsecured medication until later and discovered during her investigation that the medications had been left unsecured in the break room by the LPNs. The facility's Controlled Medication Policy required that all new schedule II-IV medications be entered into a bound narcotic book upon arrival and that the count be verified, but it did not specify the need for immediate custody of medications upon delivery. The pharmacist was notified of the issue and contacted the delivery company to ensure future deliveries would be handed off to a person rather than left unattended.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Luverne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Mary Jane Brown | 1.1 mi | ★★★★★ | 8 | 0 |
| Tuff Memorial Home | 12.1 mi | ★★★★★ | 9 | 0 |
| Parkview Manor Nursing Home | 14.1 mi | ★★★★★ | 10 | 0 |
| Palisade Healthcare Center | 14.5 mi | ★★★★★ | 5 | 1 |
| Edgebrook Care Center | 15 mi | ★★★★★ | 12 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.